HUD-53039-A Section 184A Native Hawaiian Housing Loan Guarantee Cert

OMB Approval No.
(exp: ).

Section 184A
Native Hawaiian Housing Loan Guarantee Certificate
U.S. Department of Housing and Urban Development, Office of Public and Indian Housing
1. 184 Case Number:

2. Amortization Plan:

3. LTV Ratio:

4. Living Units:

5.Closing Date:

6. Cohort #:

7. Name of Borrower (last, first, MI):

8. Social Security Number:

9. Mortgage Amount:

10. Interest Rate:

11. Monthly Payment (P&I):

12. Name of Co-Borrower (last, first, MI):

13. Social Security Number:

14. Maturity Date:

15. First Payment:

16. Endorsement Date:

17. Address of Property:

18. Lender's Name, Address & ID Number:

Endorsed for guarantee when signed below by an authorized agent of the Secretary of the U.S. Department of Housing and Urban
Development. A copy of this certificate must accompany any claim for guarantee benefits submitted to HUD.

This certificate, when endorsed above by an authorized agent of the Secretary of the U.S. Department of Housing and Urban
Development, is evidence of guarantee of the mortgage loan described herein under Section 184A of the Housing and Community
Development Act of 1992 (P.L. 102550) and regulations of the U.S. Department of Housing and Urban Development published
In Code of the Federal Regulations (24 CFR Part 1007).
Sensitive Information: The information collected on this form is considered sensitive and is protected by the Privacy Act. The Privacy
Act requires that these records are maintained with appropriate administrative, technical, and physical safeguards to ensure their security
and confidentiality. In addition, these records should be protected against any anticipated threats or hazards to their security or integrity
which could result in substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom the information is
maintained.

Privacy Act Statement. This statement is provided pursuant to the Privacy Act of 1974, 5 USC § 552a. The authority for
Form HUD-53039-A (date)

OMB Approval No.
(exp: ).

collecting personally identifiable information (PII) in the Regulatory Consistency Communication Board (RCCB) Electronic
Feedback Form is based in Section 313 of Public Law 112-95.
Public reporting burden for this collection of information is estimated to average zero hours per response, including the time
for reviewing instructions, searching existing data sources, gather and maintaining the data needed, and completing and
reviewing the collection of information. HUD may not collect this information, and you are not required to complete this
form, unless it displays a currently valid OMB control number.
This information is required in order for an eligible homebuyer to obtain a benefit and for HUD to administer the Loan
Guarantee Program for low-income Native Americans, Alaska Natives, and native Hawaiians (24 CFR Parts1000 and 6000).
The requested information is necessary to determine the income and credit worthiness of low income homebuyers. If HUD
did not collect this information, it would prevent HUD from guaranteeing mortgages to eligible homebuyers. While no
assurances of confidentiality are pledged to respondents, HUD generally discloses this data only in response to a Freedom of
Information request.

Form HUD-53039-A (date)